Laparoscopy in young children. Endoscopic surgery in children

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The study in all cases is carried out in the operating room under general anesthesia with artificial ventilation, since pneumoperitoneum can significantly limit the movements of the diaphragm, especially in young children.

Before starting the manipulation, in all cases, a thorough deep palpation of the abdominal cavity under anesthesia is carried out, which often makes it possible to more clearly determine the presence and location of swollen intestinal loops, tumor-like formations, inflammatory infiltrates, intussusception, etc. In addition, during palpation the sufficiency of gastric emptying and Bladder.

For initial entry into the abdominal cavity, we widely use a special method of direct puncture with a blunt-pointed trocar. A skin incision is made with a length slightly less than the diameter of the trocar that is supposed to be inserted in this place (usually 5.5 mm, in the presence of peritonitis - 11 mm) - most often in the area of the umbilical ring along its upper edge (Figure 7a). Then, in young children, the surgeon lifts the anterior abdominal wall with his left hand. A sharp “mosquito” type clamp is inserted through this incision, with which the fascia and aponeurosis are separated without opening the abdominal cavity (Figure 7b). In the same position, but with the help of a blunt clamp (Billroth type), the peritoneum is opened (Figure 7c).

Figure 7. Stages of pericial entry into the abdominal cavity using the method of right puncture with a blunt trocar in young children

The moment of penetration into the abdominal cavity is usually clearly felt by the surgeon. In this case, you can almost always notice the characteristic sound of air being “sucked” into the abdominal cavity. Without changing the position of the left hand, which lifts the anterior abdominal wall, a blunt-ended trocar is inserted through the incision (Figure 7d). In older children, especially with pronounced subcutaneous fat, the surgeon's assistant also helps to raise the anterior abdominal wall (Figure 8).

Figure 8. Stage of primary entry into the abdominal cavity in older children

The correct position of the trocar is always controlled using a 5 mm telescope inserted into it with a viewing angle of 30° with a miniature endovideo camera. Careful adherence to all the listed rules for performing the first puncture of the abdominal cavity allows you to avoid serious complications - bleeding or injuries to internal organs. Having ensured that the trocar is correctly positioned, C0 2 insufflation begins using an electronic insufflator. The volume of gas used is 1-1.5 liters in small children, up to 3-5 liters in adolescents. The level of intra-abdominal pressure ranges from 5-8 mm Hg. Art. in newborns and infants up to 10-14 mm Hg. Art. at an older age.

The second trocar (3-5.5 mm) is inserted in the left iliac region under the control of the endovideo system. Using a video laparoscope and a palpatir probe (or an atraumatic clamp) inserted through the trocar sleeve in the left iliac region (Figure 9), an inspection of the abdominal cavity is performed. First of all, the place where the manipulator enters the abdominal cavity is examined, which, if necessary, is freed from the strands of the omentum. Then a panoramic examination of the entire abdominal cavity is performed, during which the presence of effusion, the condition of the intestinal loops and peritoneum are assessed.

Figure 9. Operating approaches for diagnostic laparoscopy. Trocar insertion sites:
1 - trocar 5.5 mm (for palpator); 2- trocar 5.5 mm (for laparoscope 5 mm, 30 o)

The audit begins with a search for the dome of the cecum. In young children, the dome is usually located higher, in the right lateral canal, sometimes under the right lobe of the liver. There is also increased mobility of the cecum - in these cases, its dome can be found medially, among the loops of the small intestine in the middle floor of the abdominal cavity. A long cecum with a dome localized in the pelvic area is often found. Thus, if the cecum is absent in the right iliac fossa and there are difficulties in detecting it, it is advisable to begin the examination with the transverse colon.

Consistently moving the laparoscope along the tenia towards the ileocecal angle, using a manipulator and changing the position of the patient’s body, the localization of the dome of the cecum is determined. Bringing the appendix into view when using a manipulator is not difficult. Some difficulties may arise in the presence of congenital adhesions in the ileocecal region. This is Lane's ligament, which fixes the distal loop of the ileum to the iliopsoas muscle. In this case, the appendix may be located behind the ileum. The Jackson membrane, which is a membranous cord that fixes the cecum and ascending colon to the parietal peritoneum of the right lateral canal, also makes inspection difficult. If these adhesions are pronounced in the area of the dome of the cecum, the appendix may be located in a narrow retrocecal pouch.

In case of difficulties of this kind, it is necessary to turn the patient on the left side, find the base of the process, and, carefully prying it up with a manipulator (or grabbing it with a soft clamp), apply slight traction. Usually in this position it is possible to bring it into view.

After detecting the appendix, it is examined. The normal vermiform appendix is mobile, easily moved by a manipulator, its serous membrane is shiny and pale pink in color (Figure 10). The presence or absence of inflammation in it is judged by direct and indirect signs. We include the presence of a cloudy effusion in the immediate vicinity of the appendix, a reaction of the peritoneum in the form of hyperemia, the disappearance of its natural luster, and the presence of fibrin deposits as indirect signs.

Figure 10. Endoscopic picture of an unchanged appendix

Direct signs are detected by direct examination of the appendix. To these we include the injection of the serosa, its hyperemia, the disappearance of the natural shine of the serosa, a change in its natural color both in individual areas and as a whole, infiltration of both the wall of the appendix and its mesentery, the presence of fibrin deposits. In this case, it is possible to “palpate” the tension of the process and observe its rigidity (Figure 11). Inflammatory changes are more often expressed in the distal part of the process. In addition, it is often possible to detect the presence of loose adhesions between the process and surrounding tissues. In some cases, in the presence of gangrenous changes in the wall of the process, a perforation hole is detected.

Figure 11. Endoscopic picture of a phlegmonous changed appendix

The greatest difficulties arise in the differential diagnosis of the initial stages of destructive inflammation and superficial inflammation of the appendix. In this case, of all the described signs, it is possible to detect only mild hyperemia of the serosa and its injection by blood vessels. The only differential diagnostic feature that allows us to distinguish the initial stage of destructive inflammation in the appendix from a superficial inflammatory reaction is its rigidity.

Using this sign, it is possible to identify destructive inflammation in the appendix even in its early stages. This sign is defined as follows: the vermiform appendix is raised by a manipulator placed under it in the middle third. If at the same time the vermiform appendix sagged, as if falling from the manipulator, this sign was considered negative (Figure 10). If it holds the shape of the rod either in its entirety or on a separate one area, this sign is considered positive (Figure 11).

It should be noted that this sign is the most reliable of all existing ones and is used by us as a pathognomonic endoscopic symptom.

Significant difficulties arise in the differential diagnosis of pronounced secondary changes in the appendix from truly destructive changes in it. Thus, with primary pelvioperitonitis, severe mesadenitis or another source of inflammation of the abdominal cavity, secondary changes in the appendix are detected.

Swelling of the serous membrane is noted, its vessels are full-blooded, dilated, and appear in the form of a network enveloping the appendix. Unlike primary inflammation, there is no rigidity (deep layers are not involved in the process), and there is also no uniform hyperemia and compaction of the process. Thus, visible secondary changes in the appendix represent serositis and are a consequence of contact with an inflammatory effusion.

If there is no destructive inflammation in the appendix, a careful gentle inspection of the abdominal organs is performed using the following method.

Since the patient is in the Trendelenburg position with a turn on the left side during examination of the appendix, it is first convenient to examine the ileocecal angle and the mesentery of this section of the intestine (Figure 12). In childhood, a common cause of abdominal pain is acute mesenteric lymphadenitis. In the mesentery of the ileocecal angle, in the mesentery of the small intestine, enlarged, swollen and hyperemic lymph nodes are detected.

Figure 12. Position of the patient on the operating table when examining the ileocecal angle and appendix

Sometimes enlarged lymph node packets resemble “bunches of grapes”. Then the ileum is examined retrogradely at a distance of at least 60-80 cm from the ileocecal angle. In this case, we use a palpator probe, examining the small intestine loop by loop. This allows us to identify a wide variety of pathologies: Meckel's diverticulum. angiomatosis. inflammatory diseases, neoplasms, etc.

By increasing the angle of the table in the Trendelenburg position. The pelvic organs are examined, where in girls attention is drawn to the uterus and appendages. First, the right appendage is examined, then, with the table tilted sideways, but maintaining the Trendelenburg position, the left appendage is examined.

In the same position, the internal rings of the right and left inguinal canals are examined. Attention is drawn to their consistency; in addition, in boys, a testicle is sometimes found in these areas, indicating the presence of an abdominal form of cryptorchidism. Here the vas deferens and vessels of the testicles are examined.

Then the patient is given the Fowler position with a turn on the left side, in which the right lobe of the liver, the gallbladder, the area of the hepatoduodenal ligament, the pyloric part of the stomach, the duodenal bulb, and the contours of the lower pole of the right kidney are examined. Having eliminated the lateral rotation of the table, but maintaining the Fowler's position, examine the left lobe of the liver, the round and falciform ligaments of the liver, the anterior wall of the stomach, the area of the lesser omentum and the gastrocolic ligament.

It is more difficult to examine the spleen, which is located high under the diaphragm and is covered by the omentum, and in small children it is also covered by the left lobe of the liver. The patient must be turned on his right side and the head end of the table raised. By displacing the omentum and intestinal loops with a manipulator, the spleen is brought into view. Its mobility depends on the severity of the ligamentous apparatus, however, it is usually possible to clearly see the anterior end, upper edge, diaphragmatic surface and hilum area. Normally, the area of the left kidney is not visible. The inspection of the upper and middle floors of the abdominal cavity ends with an examination of the loops of the small intestine. Using a manipulator, you can methodically examine the entire intestine, its mesentery, the abdominal part of the aorta, and the place of its bifurcation.

A gentle laparoscopy technique that takes into account age-related characteristics in children, and the use of modern pediatric models of laparoscopes allow a fundamentally new approach to the diagnosis of appendicitis. The use of puncture laparoscopy in case of questionable results of other research methods allows not only to accurately determine the presence or absence of inflammation in the appendix, but also, when excluding the diagnosis of acute appendicitis, to conduct a gentle examination of the abdominal organs and in more than 1/3 of patients to identify the true cause of abdominal pain syndrome. Most often, nonspecific mesadenitis, gynecological diseases in girls, cryptogenic pelvioperitonitis, diseases of the biliary system and ileocecal angle are detected.

Analyzing the data obtained from diagnostic laparoscopy, the following options for further tactics can be identified:

1. The study ends at the diagnostic stage, and no pathology is detected.

2. The study ends at the diagnostic stage, which reveals pathology of the abdominal organs that requires conservative treatment.

3. As a result of the diagnostic stage of laparoscopic intervention, diseases of the abdominal organs are identified, the treatment of which can be carried out using laparoscopic interventions.

4. At the diagnostic stage of laparoscopic intervention, diseases are identified that cannot be treated laparoscopically. These patients undergo laparotomy.

D.G. Krieger, A.V. Fedorov, P.K. Voskresensky, A.F. Dronov

Our expert is a surgeon, head of the urology department of the Volgograd Clinical Hospital of Emergency Medicine, Sergei Bondarenko.

Not long ago, laparoscopic surgeries, which are performed through one or more tiny holes in the body, were science fiction. Something like the work of Filipino healers. Today, the indications for such operations are expanding day by day, and these interventions themselves are used not only in adults, but also in children.

Small access - big benefit

Once upon a time, doctors used the following phrase: “Big surgeon, big incision.” But this statement has long since lost its relevance. And all thanks to the introduction of so-called minimally invasive (that is, gentle) surgical methods. After all, such operations (as doctors say, with limited access) do not require large incisions, but are carried out through barely noticeable 3-4 punctures, which are made in the patient’s anterior abdominal wall. Through these holes, miniature manipulative instruments are inserted, which the surgeon uses to perform the operation. An optical device with a light source is inserted through another puncture. Modern optics are connected to a monitor screen, where a detailed and comprehensive image of the internal organ is displayed. You can view it in detail, and you can also use the image enlargement function. Naturally, an excellent overview of the surgical field is very convenient for the surgeon, which improves the quality of his work.

There are also benefits for the patient. Blood loss after laparoscopic operations is less, pain is lower, and the cosmetic result is better. Healing occurs faster, the rehabilitation period is simpler and shorter. And there are significantly fewer complications. Of course, at first glance, such operations represent a complete benefit for both the doctor and the patient. But is it really that simple?

Fundamental question

When using laparoscopic techniques, especially when it comes to pediatric surgery, some important principles must be observed. The main one is the principle of safety.

Passing optics and instruments into the patient's abdominal cavity is the most dangerous moment during the operation, since for the surgeon this process always occurs blindly. Doctors have to be especially careful if a small patient has anatomical anomalies - in this case, there is a higher risk of accidentally damaging important organs and tissues. And even the data from available studies (ultrasound, MRI) do not always guarantee safety. When performing laparoscopy in adults, air is pumped into the abdominal cavity - this is done in order to lift the abdominal wall and facilitate the insertion of instruments. But, alas, this method cannot be used for children, since for them the pressure in the abdominal cavity exceeds 7-8 mm Hg. Art., is harmful, it can have an extremely negative effect on the child’s cardiac activity, respiratory system and brain. Therefore, surgeons use different tricks when inserting instruments. For example, they use the “open port” technique - that is, before introducing instruments, they make a small incision (5-6 mm), through which all the anatomical details of interest will be clearly visible. The second way to ensure safety is to insert a Veress needle, a device that is a hollow needle with a spring inside and a cannula. After penetration into the cavity (usually the abdominal cavity), the protective part of this instrument extends and covers the needle tip, thereby protecting the organs and tissues located there from damage.

Jewelry work

The second important principle that is used today in pediatric laparoscopic surgery is the principle of minimal invasiveness. Doctors are confident that a small approach must be combined with minimally invasive (that is, gentle) surgery, then this justifies the essence of the method itself and guarantees the absence of postoperative injuries for the patient. Therefore, doctors performing laparoscopic operations on children try to work very carefully and literally with precision. This principle also implies the most gentle attitude when intervening to neighboring healthy organs and tissues. With an open operation, this is almost impossible to achieve, since the surgeon’s eyes cannot provide such a detailed image as a video camera can, showing the organ from all sides. In addition, manual manipulation is always more traumatic than working with thin instruments. In this regard, laparoscopic surgery provides great advantages.

Dangerous repetition

Repeated operations require special attention, the difficulty of which lies in the fact that the surgeon starting work does not fully know the severity of the scar process left in a small patient after the previous intervention. After all, any healing in the body occurs through the formation of scar tissue. However, the degree of scarring may vary. Therefore, the most difficult stage of such an operation is the isolation of the organ, since it is quite problematic to excise the surrounding scars, since they often include important tissues, for example, vessels that feed the organs. Therefore, few surgeons, even in the world, decide to perform repeated laparoscopic operations, which are difficult not only technically, but also physically and psycho-emotionally. However, if we talk about urology, the risk of losing a kidney with repeated open surgery is higher than with repeated laparoscopic surgery. That’s why doctors still resort to these complex methods. And they often achieve excellent results.

To apply sutures, two 5 mm instruments are required: a Szabo-Berci type needle holder (located in the right hand) and an atraumatic grabber (in the left).

The most commonly used are conventional surgical sutures with curved needles (Vicryl, PDS 4 0, 5 0).

The following types of seams are usually used:

1. Single sutures for suturing small defects of the peritoneum, suturing and ligating structures such as the ureter, urachus, etc., cecopexy, etc. The diagram for applying such a suture is shown in Fig. 4 8;

Rice. 4 8. Scheme of applying a single suture.

Features of operational technology

2. Continuous suture, mainly when closing fairly large peritoneal defects after extensive mobilizations of the colon (during kidney operations), during laparoscopic orchipexy, etc. (Fig. 4 9).

4.2. Final stages of intervention

Revision of the abdominal cavity 1. Thorough examination of the abdomen

cavity starting from the small pelvis to the upper floor of the abdominal cavity in order to detect previously undetected injuries to internal organs.

2. An inspection to detect bleeding sites is carried out after the intra-abdominal pressure has decreased to 5 mm Hg. Art., and venous bleeding resumes, which is tamponed at a pressure in the abdominal cavity of about 15 mm Hg. Art.

Abdominal sanitation

1. Complete removal of effusion from the abdominal cavity using endoscopic suction.

2. According to indications - targeted dosed rinsing of the entire abdominal cavity or its individual parts with physiological solution with the addition of heparin, followed by complete removal of the rinsing solution.

3. If necessary - dr-

Rice. 4 9. Scheme for applying a continuous suture.

lining the abdominal cavity with silicone drainage. Handset

it is precisely inserted into the desired part of the abdominal cavity under the control of a laparoscope. In our observations, the indication for drainage is most often the presence of peritonitis. After “pure” planned surgical interventions, abdominal drainage is usually not performed.

Laparoscopic surgery. a common part

Trocar removal

1. First of all, 12 and 11 mm trocars are removed, always under endoscopic control of the place where they are located, in order to avoid possible bleeding (when using trocars with a conical stylet shape, this practically does not happen) or a strand of the omentum entering the peritoneal defect (this most often happens when the trocar removed after complete removal of pneumoperitoneum and the appearance of tension in the muscles of the anterior abdominal wall after the end of the action of muscle relaxants).

2. Layer-by-layer suturing of an 11 mm wound is also advisable to carry out until the pneumoperitoneum is completely removed and under optical control. The wound is closed in layers with mandatory suturing of the fascia (Vicryl 4 0) and skin.

3. After removal of the pneumoperitoneum, 5 mm trocars are removed, and the skin wounds in the places where they are located are closed with adhesive plaster strips or one suture is applied.

Literature

1. Emelyanov S., Matveev N.L., Fedenko V.V., Evdoshenko V.V. Manual suture in laparoscopic surgery // Endoscope, surgeon. - 1995. - No. 2-3. -

pp. 55 62.

2. Box N.M.A., Georgeson K.E., Najmaldin A., Valla J.S.Endoscopic Surgery in Children. Berlin; Heidelberg: Springer Verlag, 1999, pp. 14 35.

3. Nathanson L.K., Nathanson P.D., Cuscheri A.Safety of Vessel ligament in laparoscopic surgery // Endoscopy. - 2001. - Vol. 23. - P. 206-209.

4. Sabo Z, Hunter J. G., Litwin D. T., Berci G. Training for Advanced Laparoscopic Surgical Skills. - San Francisco: Surgical Universal Medical Press, 1994. - P. 118-

5. Zucker K.A., Bailey R.W., Graham L. et al.Training for laparoscopic surgery // World J. Surg. 1993. Vol. 17.No. 1. P. 3 7.

CHAPTER 5.

Laparoscopic surgical techniques place great demands on adequate anesthesia and intraoperative monitoring. Despite the accumulation of significant experience in ensuring adequate protection of the patient during surgery, when performing laparoscopic interventions, the anesthetic risk still remains significantly higher than the surgical risk.

In the middle of the 20th century, doctors paid serious attention to changes in the hemodynamic and gas exchange systems caused by the imposition of pneumoperitoneum. Laparoscopy turned out to be far from a safe procedure. Performing these operations is associated with the occurrence of minor and major surgical and anesthetic complications, to prevent and relieve which it is necessary to clearly understand the pathophysiological mechanisms of their development.

5.1. The effect of laparoscopic manipulation on ventilation and gas exchange

Currently, the vast majority of anesthesiologists note the danger of performing laparoscopic manipulations and operations against the background of spontaneous breathing, since the imposition of pneumoperitoneum limits the mobility of the diaphragm.

The application of pneumoperitoneum causes the following changes in the functioning of the child’s cardiovascular system:

1. The extensibility of the lung tissue decreases.

2. Atelectasis of areas of the lungs occurs.

3. The functional residual capacity of the lungs decreases, ventilation-perfusion disorders appear and progress, hypoventilation, hypercapnia and respiratory acidosis develop.

With an increase in the area of pulmonary shunting (i.e., areas of perf JnpyeMoft, but not ventilated lung tissue), hypoxemia increases, which is not corrected by increasing the percentage of oxygen in the inhaled mixture. This is reflected in a decrease in the value of such indicators as partial

real oxygen pressure in arterial blood (pa02) and hemoglobin oxygen saturation (S02). Typically, oxygen deprivation occurs in patients with underlying myocardial dysfunction and/or hypovolemia and is associated with the combined effects of reduced pulmonary compliance and reduced cardiac output (CO).

That is why, when performing laparoscopic procedures, there is a need for tracheal intubation, mechanical ventilation and total muscle relaxation. However, even against the background of mechanical ventilation in the normal ventilation mode with a complete muscle block, atelectasis of the alveoli and a decrease in pulmonary compliance occur.

Laparoscopic surgery. a common part

tissue, a decrease in FOB, an increase in peak pressure and plateau pressure in the airways (by an average of 40%). These changes are more pronounced during laparoscopic operations, which are performed in the Trendelenburg position and require maintaining high pressure in the abdominal cavity (5-14 mm Hg). Disturbances from the respiratory system are much less significant during laparoscopic cholecystectomies, during which a reverse Trendelenburg position is used and the pressure in the abdominal cavity does not exceed 10-14 mm Hg. Art.

Hypercapnia during laparoscopic procedures is caused not only by changes in ventilation parameters as a result of increased intra-abdominal pressure, but also by the absorption of carbon dioxide (CO2) from the abdominal cavity. CO2 is highly soluble in the blood and quickly diffuses through the peritoneum.

Factors that determine the intensity of CO2 entry into the blood:

1. Good solubility C0 2 in the blood, rapid diffusion through the peritoneum.

2. Abdominal pressure level.

3. Duration of surgery.

4. Absorption surface area (peritoneum).

Since the last parameter per unit of body weight in children is 2 times greater than in adults, a faster and more massive intake of CO2 into the blood can be expected in children. In adults, hypercapnia and respiratory acidosis usually develop no earlier than 15 minutes after the start of CO2 insufflation into the abdominal cavity, while in children these changes occur immediately after the application of pneumoperitoneum.

The absorption of CO2 into the blood when pneumoperitoneum is applied using CO2 is reflected in an increase in the concentration of CO2 at the end of expiration (ETC02), partial pressure of CO2 in arterial blood (pa CO2), the level of CO2 production by the lungs (VC02), and in the development of acidosis. In some patients, there is an increase in the difference between pa CO2 and ETC02; at the same time, the occurrence of uncontrollable acidosis is observed. An explanation for this fact is found in the presence of reduced CO and, as a consequence of this, increased venous shunting in the lungs and reduced splanchnic blood flow.

Some authors note an increased release of CO2 by the lungs even after removal of pneumoperitoneum. Values of VC02, ETC02, and Pa CO2 that exceed the normal level can be observed during the first 30–180 minutes of the postoperative period. This occurs because 20-40% of absorbed CO2 remains in the patient's body after CO2 is removed from the abdominal cavity.

Possible ways to prevent and correct emerging ventilation and gas exchange disorders:

1. Use of endotracheal anesthesia against the background of total muscle relaxation.

2. Ventilation in hyperventilation mode (at 30-35% more than normal). In this case, mechanical ventilation can continue after the end of surgery until ETC02 and CO2 pa are normalized.

3. Using CPAP (Continuous Positive Airway Pressure Expiratory Pressure) modes.

Features of pain relief during laparoscopic operations

It must be remembered, however, that in cases where the progression of acidosis is partially associated with a decrease in peripheral perfusion, hyperventilation may not provide a pronounced compensatory effect, since it itself can cause a decrease in CO. Probably the most rational option for mechanical ventilation is high-frequency injection mechanical ventilation, which reduces the negative impact of carboxyperitoneum on central hemodynamics, gas exchange and respiratory function.

If progressive hypercapnia, acidosis, hypoxemia occurs against the background of hyperventilation, the following measures are performed sequentially until the desired effect is achieved:

1. Ventilation 100% Og

2. Maintenance of cardiac output and peripheral perfusion by various methods.

3. Return the patient to a horizontal position.

4. Removal of CO 2 from the abdominal cavity.

5. Transition from laparoscopy to laparotomy.

5.2. The influence of laparoscopic manipulations on hemodynamics

An increase in pressure in the abdominal cavity when applying pneumoperito neum can influence the CO value in two ways: contribute, on the one hand, to the “squeezing out” of blood from the abdominal organs and the inferior vena cava to the heart, on the other, to the accumulation of blood in the lower extremities with a subsequent natural decrease in venous return. The prevalence of one or another effect depends on many factors, in particular on the magnitude of intra-abdominal pressure. It has been noted that the position opposite to the Trend Elenburg position contributes to the development of more serious hemodynamic changes, since in this case the influence of high intra-abdominal pressure is combined with the gravitational effect on the return of blood to the heart with the natural development of venous stagnation in the periphery and a pronounced decrease in preload for the left ventricle , and SV. The Trendelenburg position, on the contrary, is favorable for maintaining proper CO values, as it helps to normalize venous return and thereby increase the central blood volume in conditions of pneumoperito-cheum.

The application of pneumoperitoneum helps to increase peripheral vascular resistance due to external compression of arterioles, in particular the splanchnic basin. Pressure in the abdominal cavity increased to a certain level can cause compression of the aorta. Renal blood flow is also significantly affected.

Along with the above factors, hypoxemia, hypercapnia and respiratory acidosis have a certain effect on hemodynamics. On the one hand, CO2, directly affecting the vascular wall, causes vasodilation, compensating for the increase in peripheral vascular resistance. On the other hand, both hypoxemia and a decrease in blood pH stimulate the sympathetic adrenal system, thereby promoting mass

Laparoscopic surgery. a common part

strong release of catecholamines. All this can lead to an increase in CO, peripheral vascular resistance, blood pressure, the development of tachycardia, cardiac arrhythmias, and even cardiac arrest.

If severe disturbances occur in the circulatory system, all experts recommend removing pneumoperitoneum and switching to laparotomy.

An increase in intra-abdominal pressure during laparoscopic operations creates the prerequisites for the occurrence of gastroesophageal regurgitation with subsequent aspiration of acidic gastric contents. The risk of developing this complication is especially high in patients with gastroparesis, hiatal hernia, obesity, pyloric gastric obstruction, outpatients and children (due to the lower pH of gastric contents and the higher ratio of the latter to body weight). Perhaps the high probability of gastroesophageal reflux with subsequent aspiration limits the use of the laryngeal mask, which is currently widely used during laparoscopic surgical interventions.

The following measures to prevent regurgitation are suggested:

1. Preoperative use of metoclopramide (10 mg per os or intravenously)

rivenno), which increases the tone of the cardiac sphincter of the stomach, and H2 blockers, which reduce the acidity of gastric contents.

2. Preoperative gastric lavage followed by insertion of a gastric tube (after tracheal intubation); the presence of a probe in the stomach, in addition, prevents injury to the stomach when pneumoperitoneum is applied and improves visualization of the surgical field for surgeons.

3. Tracheal intubation is mandatory, and it is desirable that the endotracheal tube have a cuff.

One of the most dangerous, potentially fatal complications of paw-

roscopic surgery is gas embolism. CO2 is quickly absorbed through the peritoneum and absorbed into the splanchnic vessels. Since it is highly soluble in the blood, the entry of a small amount into the blood

the current passes without visible complications. Massive absorption of CO2 leads to gas embolism.

Prerequisites for the development of CO2 embolism:

1. Reduced splanchnic blood flow, which is observed with high intra-abdominal pressure.

2. The presence of gaping venous vessels as a result of surgical trauma. Clinical signs of gas embolism are a significant decrease in blood pressure, cardiac dysrhythmias, the appearance of new cardiac murmurs, cyanosis,

pulmonary edema, increased ETC02 levels, i.e. There is a picture of the development of right ventricular heart failure against the background of pulmonary hypertension and hypoxemia. Early diagnosis of this complication requires careful monitoring of ECG, blood pressure, heart sounds and ETC02.

When diagnosing gas embolism, it must be remembered that collapse can also be observed with bleeding, pulmonary embolism, myocardial infarction, pneumothorax, pneumomediastinum, high intra-abdominal pressure, and pronounced vagal reflexes.

Features of pain relief during laparoscopic operations

5.3. Selection of anesthetic aid

Anesthesiologists working with children point out the need for a careful history taking in patients undergoing laparoscopic surgery. An absolute contraindication to such operations is fibrous dysplasia of the lungs.

Contraindications for emergency laparoscopy in children:

1. Coma.

2. Decompensated heart failure.

3. Decompensated respiratory failure.

4. Severe bleeding disorders (Quick test value below 30%, significant increase in bleeding time).

5. Borderline conditions in which laparoscopy can cause the above complications.

The use of various techniques of local anesthesia with preserved spontaneous breathing in adults is still under debate. In pediatric practice, this method is unacceptable, since it is impossible and impractical to perform epidural anesthesia or bilateral intercostal block in a conscious child. The use of epidural anesthesia as part of combined anesthesia, despite some advantages, is often accompanied by hemodynamic disorders and does not prevent irritation of the phrenic nerve (C1P-Cv), nausea and vomiting in the postoperative period.

Advantages of general endotracheal anesthesia:

1. Improving the working conditions of surgeons with total muscle relaxation and the presence of a gastric tube. Deep sedation of the patient makes it easy to give him the desired position.

2. Tracheal intubation ensures a clear airway and prevents aspiration (when the endotracheal tube cuff inflates).

3. Cardiopulmonary changes caused by CO2 injection 2 into the abdominal cavity can be eliminated by maintaining proper levels of minute ventilation, oxygenation and circulating blood volume (CBV).

For general endotracheal anesthesia, different specialists offer a wide variety of schemes, which, as a rule, differ little from the methods of general anesthesia for conventional surgical interventions. The accumulated experience and research conducted on the characteristics of pain relief for laparoscopic operations in children allow us to formulate the following practical recommendations for conducting anesthesia in a pediatric clinic.

Premedication. For the purpose of premedication, children are administered intramuscularly with 0.1% atropine at a rate of 0.01 mg/kg, 0.5% relanium 0.35 mg/kg for children aged 1-3 years, 0.3 mg/kg for children aged 4- 8 years and 0.2-0.3 mg/kg for older patients. The differentiation is due to the weaker sensitivity of patients in the younger age group to ataracts. If there is a history of allergies, premedication includes diphenhydramine or Rastin soup at a dose of 0.3-0.5 mg/kg.

Laparoscopic surgery. a common part

The choice of anesthetic remains with the anesthesiologist. Traditionally, inhalation anesthesia using fluorothan (halothane, narcotan) is widely used in children's clinics. This halogen-containing anesthetic is so popular due to its rapid induction into general anesthesia and rapid awakening, ensuring sufficient depth and controllability of anesthesia. Ftorotan is used according to the traditional scheme, adhering to the minimum sufficient concentrations of the anesthetic in the inhaled mixture. The use of a combination with nitrous oxide (N02) is permissible only at the stage of induction of anesthesia. In the future, taking into account the ability of N2 0 to actively accumulate in the physiological and pathological cavities of the body and its potentially hypoxic effect, ventilation should be carried out with 100% O2

The pronounced cardiodepressive effect of ftorotan is manifested by a decrease in CO, a slowdown in atrioventricular conduction, and a decrease in blood pressure. Of the modern and available drugs for anesthesia, diprivan and midazolam were chosen as alternative drugs to fluorotane that do not give such pronounced side effects.

Midazolam, synthesized in 1976, is one of the many representatives of the benzodiazepine group. It has the ability to quickly bind to GABAergic and benzodiazepine receptors. As a result, a few (5-10) minutes after intramuscular administration, the patient develops rapid psychomotor inhibition, and upon completion of the administration, he quickly returns to normal activity. It is necessary to note the pronounced anxiolytic, sedative and anticonvulsant effects and low allergenicity inherent in midazolam,

A also the fact that when using it there is a significant antero

And retrograde amnesia. This drug compares favorably with ftorotan due to its minimal effect on the cardiovascular and respiratory systems. Induction of anesthesia is carried out by intravenous administration of midazolam(0.3-0.4 mg/kg for children 1-3 years old, 0.2-0.25 mg/kg for children 4-8 years old, 0.1-0.15 mg/kg for children 9-14 years old) in combinations with intravenous fractional administration of fentanyl and muscle relaxant comrade. The maintenance period is a constant infusion of midazolam 0.3-0.4 mg/kg per hour in combination with intravenous fractional administration of fentanyl and miorelak santov. The administration of midazolam is stopped 8-12 minutes before the end of anesthesia.

Diprivan (propofol) has a mechanism of action similar to benzodiazepine drugs. Its advantages include:

1. Rapid onset of hypnotic effect.

2. High metabolic rate.

3. Mild recovery period.

These properties ensure that Dipriv is becoming increasingly widespread in clinical practice. Like most anesthetic agents, diprivan affects respiratory function, causing depression of spontaneous breathing during the induction stage of anesthesia. The drug can cause hypotension due to a decrease in total peripheral resistance. The administration of diprivan in a clinically effective dose is usually accompanied by a decrease in heart rate, which is explained by the vagotonic effect of the drug and blood pressure.

Features of pain relief during laparoscopic operations

is treated with preemptive administration of atropine or metacin. Induction of anesthesia is carried out by intravenous administration of 2.5 mg/kg diprivan. The maintenance period is a constant infusion of diprivan 8-12 mg/kg per hour in combination with fractional administration of fentanyl and muscle relaxants. The administration of diprivan is stopped 6-10 minutes before the end of anesthesia.

5.4. Artificial ventilation, infusion therapy

and monitoring

Ventilation Ensuring adequate gas exchange is possible only when using mechanical ventilation in hyperventilation mode. In the intermittent positive pressure ventilation mode, the tidal volume is calculated using the Radford nomogram. The respiratory rate corresponds to the age norm. The inspiratory pressure is set for each patient depending on age and individual characteristics in the range of 14-22 mbar. Expiratory pressure 0. After pneumoperitoneum is applied, the minute volume of ventilation increases by 30-35%, due to an increase in both tidal volume and respiratory rate.

All patients after tracheal intubation are recommended to insert a tube into the stomach and catheterize the bladder. This not only prevents dangerous complications (aspiration of gastric contents, perforation of hollow organs with a trocar), but also improves visualization of the surgical field by surgeons.

Infusion therapy. The use of a forced infusion load regime makes it possible to prevent the development of hemodynamic disorders caused by the state of relative hypovolemia provoked by pneumoperitoneum. Intravenous infusion therapy can be carried out with crystalloid solutions (for example, Inosteril from Frisenius). If it is necessary to correct intraoperative blood loss, infusion transfusion therapy is performed. In these cases, single-group fresh frozen plasma, plasma protectors (reopolyglucin, polyglucin), polyionic crystalloid solutions, and 5-10% glucose solutions are used. When Hb is less than 100 g/l and W is less than 30%, transfusion of single-group red blood cells is recommended.

Studies have shown that, regardless of the anesthetic chosen, standard infusion therapy (8-10 ml/kg per hour during planned operations and 12-14 ml/kg per hour during emergency operations) does not prevent the development of a state of relative hypovolemia caused by the redistribution of blood to the periphery with a decrease venous return, a drop in CO and stroke volume after the application of pneumoperitoneum. To correct this condition, the following infusion therapy regimen is used. From the moment of catheterization of the peripheral vein in the operating room until the moment of pneumoperitoneum is applied, the infusion rate should be 10-15 ml/kg per hour during planned operations and 15-28 ml/kg per hour during emergency operations. After gas insufflation into the abdominal cavity, it is advisable to reduce the infusion rate to 10-12 ml/kg per hour.

The MedicaMente pediatric surgery clinic in Korolev (Moscow region) provides surgical treatment of inguinal hernia in children using laparoscopy (through punctures).

Laparoscopy of inguinal hernia: how is the operation performed?

Today, endoscopic methods using a miniature video camera and microsurgical instruments are increasingly used in pediatric surgery. Parents are interested in how such operations are performed, since in the professional hands of a surgeon the technique allows one to achieve an effective treatment result with a good cosmetic effect.

Laparoscopy of inguinal hernia in children is performed exclusively under general anesthesia. The duration of the operation is on average 40-50 minutes. Using a special laparoscope device, through minor punctures in the abdominal wall, the surgeon performs a full examination of the abdominal cavity, identifies the pathological process and takes the necessary measures to eliminate it.

Pediatric surgeons at MedicaMente have accumulated significant practical experience in the use of laparoscopic techniques, including in the treatment of inguinal hernia in children. The operating unit of our clinic is equipped with all the necessary medical equipment for laparoscopic operations, including the latest endoscopic equipment designed specifically for children.

The photo below shows the results of treating an inguinal hernia in a girl using laparoscopy.

Inguinal hernia in a girl. Laparoscopy

In the photo: the girl has an inguinal hernia on the left. Laparoscopic surgery. Sutures after laparoscopy of an inguinal hernia in a child (instrument width 11 mm)

Open surgery or laparoscopy for inguinal hernia in a child?

Open treatment:

PRO: quickly 30-40 minutes, hardware-mask anesthesia,no pain in the abdomen.
CONS: scar up to 2-5 cm (depending on the surgeon). A pediatric surgeon at the MedicaMente clinic in Korolev applies an intradermal suture that does not need to be removed. The child no longer experiences unpleasant procedures. After the operation, an inconspicuous scar, only 2 cm long, remains.

Laparoscopy:

PROS: time about 45 minutes, no stitches with 3 mm instruments (there are also 6 mm ones), scar: from three 3 mm punctures. Possibility of performing hernia repair on both sides at once.
CONS: the child is under endotracheal anesthesia, periodically there is pain in the abdomen, most often the high cost of surgical treatment (even in government agencies under the compulsory medical insurance policy).

The decision to choose a surgical method is made by a pediatric surgeon after a thorough examination of the patient, an assessment of his concomitant diseases and a conversation with his parents.

Laparoscopy of inguinal hernia: cost of surgery

Below are the prices for laparoscopic treatment of inguinal hernia in children. You can find out about the prices for inguinal hernia surgery in adults.

*Price includes:

inpatient accommodation 1 day (double room with toilet, TV, cartoon channel)
anesthetic aid: anesthetic Sevoran, implementation of local blockade - Naropin
operation, all necessary operating supplies
application of an intradermal cosmetic suture - no need to remove the suture
constant telephone communication with the attending physician
examination any day in the clinic within 30 days after surgery

The cost of the operation does not include:preoperative examination (tests can be taken at the clinic at your place of residence, in our medical center - the “For surgery” panel or in any commercial laboratory)

** This is not a public offer agreement. Check the cost of services on the day of your request.